The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TRINITY HOSPITAL OF AUGUSTA 2260 WRIGHTSBORO RD AUGUSTA, GA 30904 March 28, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of medical records, facility's video recordings, Ambulance trip report, County 'A's Sheriff Officer's notes, Medical Staff Bylaws, Medical Staff Rules and Regulations, Emergency Department Professional Services Agreement, Quorum Health Corporation Code of Conduct, policies and procedures, staff and telephone interviews, it was determined that the facility failed to ensure compliance with CFR 489.24, for one individual (patient #4) out of twenty (20) sampled patients.

Findings were:

Cross refer to A-2406, as it relates to failure to provide an appropriate Medical Screening Exam (MSE) for Patient #4.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility's video recording, Ambulance trip report , County 'A' Sheriff Officer's notes, Medical Staff Bylaws, Medical Staff Rules and Regulations, ED Professional Services Agreement, policies and procedures, staff and telephone interviews, it was determined that the facility failed to ensure that a Medical Screening Examination was provided for one individual)when a Police Officer acting on behalf of the patient requested a medical screening examination for psychiatric complaint for one (#4) out of twenty (20) sampled patients.

Findings were:


Review of the facility's policies and procedures

1. EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Patient Transfer to Another Facility, policy number E-01, effective 01/2012, revealed an MSE was to be provided to determine whether an EMC existed and further examination and/or treatment necessary to stabilize any EMC unless an appropriate transfer to another medical facility is necessary. In section III. Presentments and Compliance with EMTALA, 1. The hospital ' s EMTALA obligations are triggered, and the hospital must comply with the requirements of EMTALA when an individual comes to the ED, which occurs when the individual presents to the hospital in one of the following manners:
a. When the individual presents to an area of the hospital that meets the definition of a Dedicated ED (including in an off-campus department or location that operates under the hospital ' s Medicare provider number) and requests examination or treatment for a medical condition or has such a request made on his or her behalf.
b. A request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual ' s appearance or behavior, that the individual needs such examination or treatment. ..

2. V. The Medical Screening Examination: The hospital must perform an appropriate Medical Screening Examination for every individual who comes to the Emergency Department in accordance with Section III of these guidelines. The purpose of the Medical Screening Examination is to determine if an Emergency Medical Condition exists. A. The term Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical intervention could reasonably be expected to result in (i) placing the health of the individual ...in serious jeopardy;(ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part ...Note: Questioning by a triage nurse is not sufficient to fulfill the Medical Screening Examination requirement ...3. The Medical Screening Examination must be performed within the capabilities of the hospital's emergency department ... including ancillary services routinely available to the emergency department ...5. The Medical Screening Examination must be conducted by a physician or other medical person determined qualified by the hospital's Board of trustees."


Medical Staff Bylaws and Medical Staff Rules and Regulations

Review of the Medical Staff Bylaws the revised 11/24/15, revealed in the Medical Staff Rules and Regulations,
--Section 11.1 entitled Emergency Medical Screening, Treatment, Transfers and On-Call Roster Policy, 11.1 (a) Screening. 1. Revealed any individual who presents to the ED of this hospital for care shall be provided with an MSE to determine whether that individual is experiencing an emergency medical condition (EMC). Generally, an "EMC " is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child. 2. Revealed all patients were to be examined by qualified medical personnel, which was defined as a practitioner or Allied Health Professional (AHP) credentialed for the ED or in the case of a woman in labor, a registered nurse (RN) trained in obstetric (pregnancy and childbirth) nursing where permitted under state law and hospital policy.
--The Medical Staff Bylaws defined an AHP as a credentialed individual, other than a practitioner, who is qualified to render direct or indirect medical or surgical care under the supervision of a practitioner who has been afforded privileges to provide such care in the hospital.
--Section 11.1 (b) Stabilization. 1. Required any individual experiencing an EMC to be stabilized prior to transfer or discharge, excepting conditions set forth below. 2. Revealed that a patient was stable for discharge when within reasonable clinical confidence, it was determined that the patient had reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient was given a plan for appropriate follow-up care with discharge instructions; or when the patient requires no further treatment and the treating practitioner has provided written documentation of his/her findings. 3. A patient is stable for transfer is the treating practitioner has determined, within reasonable clinical confidence, that the patient is expected to leave the hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating practitioner reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complications of that condition. The patient is considered to be stable for transfer when he/she is protected and prevented from injuring himself/herself or others.



Ambulance Trip Report

Review of Patient #4's medical record revealed that Patient #4 presented by ambulance to the facility's Emergency Department (ED) on 03/15/17 at 3:59 p.m. The ambulance trip report revealed that on 03/15/17 at 3:21 p.m., the ambulance attendants arrived to find Patient #4 "standing in the road talking with a friend". The Emergency Medical Technician (EMT) noted that Patient #4 stated that he/she had had a stroke. The EMT further noted that Patient #4 had a history of high blood pressure, was on no medications, and had no allergies, had a history of hypertension.. The EMT documented Patient #4's initial blood pressure as 192/108 (normal 120/80) and pulse 113 (normal 60-100). The EMT noted that Patient #4's physical examination was normal and that Patient #4 was not in any distress. At 3:35 p.m., the EMT noted that Patient #4's blood pressure was 193/109 and pulse was 110. The EMT noted that Patient #4 walked to the ambulance and was then transported to Trinity Hospital of Augusta. The EMT noted that during transport Patient #4's vital signs (temperature, pulse, respirations, and blood pressure) were all within normal limits. The EMT noted that upon arrival to the hospital Patient #4 walked into the ED and report was given to the Registered Nurse, RN #6.


Medical Record Reviews

Review of the medical record from Trinity Hospital of Augusta revealed that at 4:07 p.m., Patient #4 signed the Notice of Patient Rights and Responsibilities, Inpatient / Outpatient Conditions of Admission and Consent to Medical Treatment, and Informed Consent to Routine Procedures and Treatment forms.

At 4:15 p.m., RN #3 (triage nurse, the nurse who assesses patients to determine their acuity and the order in which they will be seen according to their medical needs) noted that Patient #4 "forgets why (he/she) is here but does say he/she has chest pain ". RN #3 assessed Patient #4 as being a level three (3) acuity. RN #3 further noted that Patient #4's pain level was zero (0) on a scale of zero (0 - no pain) to ten (10 - severe pain). In addition, RN #3 noted that Patient #4 appeared unkempt, was withdrawn, and had recently been discharged from a psychiatric facility where the patient had been treated for suicidal thoughts. RN #3 noted that Patient #4 did not remember why he/she was there and that Patient #4 reported that he/she kept blanking out when trying to answer questions. RN #3 noted that Patient #4's medical history included anxiety and high blood pressure. RN #3 noted that Patient #4's home medications included Zoloft (used to treat depression, anxiety, and panic disorder) 50 milligrams by mouth once a day. RN #3 noted that the Suicide Risk Assessment revealed the following:
--Patient #4 does not feel hopeless or helpless,
--In the past Patient #4 had thoughts of suicide,
--Patient #4 was not having thoughts of suicide at the present, and
--Patient #4 had no family members or acquaintances that had committed suicide, and
--Patient #4 had never witnessed a suicide.

At 4:17 p.m., RN #5 (Patient #4's primary nurse) noted that the patient's blood pressure was 182/96 and pulse was 92. RN #5 noted that Patient #4 was alert and oriented, in no apparent distress, was unkempt, cooperative, confused, and was asking "why am I here ". RN #5 noted that Patient #4 was unsure why he/she had called the ambulance. RN #5 further noted that Patient #4 denied suicidal or homicidal ideations (thoughts). RN #5 also noted that Patient #4's chest pain began one (1) hour prior to arrival and that Patient #4 wanted help with his/her blood pressure. In addition, RN #5 noted that Patient #4 stated that he/she was living in the woods.

At 4:42 p.m., Physician #2 noted that Patient #4 had initially told the EMT that he/she had left arm weakness and later told the triage nurse that he/she had chest pain. Physician #2 noted that Patient #4 stated he/she called the ambulance but was unsure why he/she was in the ED. Physician #2 noted Patient #4 was recently discharged from a Behavioral Health Unit and that the stated he/she was taking his/her medications as prescribed. The physician noted that Patient #4 denied any suicidal or homicidal ideations and that the patient said he/she was staying with his/her brother. Physician #2 documented the review of systems and the physical examination as normal. Physician #2 noted that the patient was not having any hallucinations (visual or auditory perception of something that isn't there), delusions (false belief in something despite evidence that it isn't real), inappropriate behavior, manic behavior (elevated or unusual irritability), paranoia, or thoughts of harming self or others. Physician #2 noted that the patient was medically screened for a new problem, that the symptoms had resolved, that the differential diagnosis was weakness, and that the patient was "well appearing with stable vital signs ". Physician #2 further noted that the patient had medication as prescribed by the psychiatric facility. Physician #2 noted that the patient was to be discharged home in good condition and was to follow-up with a private physician in two (2) to three (3) days or if there was any worsening of the condition.

At 5:01 p.m., RN #5 noted that Patient #4's blood pressure was 176/74. RN #5 further noted that Patient #4 was alert and oriented, had remained in no apparent distress, and had no cognitive (perception) or functional deficits. RN #5 noted that the patient verbalized understanding of the discharge instructions and that the patient received a copy of the discharge instructions.

Review of the discharge instructions revealed the instructions informed the patient that the examination and treatment received in the ED was provided on an emergency basis only and were not intended to be a substitute for an effort to provide complete medical care. The instructions informed Patient #4 that he/she should contact his/her physician for follow-up and that the patient was to inform the primary care physician of any new or remaining problems. The instructions noted that the patient had weakness and was to follow-up with a physician in two (2) to three (3) days or if the condition worsened. On the patient signature line, Patient #4 had signed " F*** It". The form was co-signed by physician #2.

RN #5 noted that the patient left the main ED on 03/15/17 at 5:09 p.m.

At 5:22 p.m., RN #3 noted that County 'A's Sheriff Office dispatcher called the ED and asked about a suicidal patient that was going to kill himself/herself. RN #3 noted that there were no registered patients in the ED at the time that were expressing suicidal or homicidal ideations. RN #3 noted that the dispatcher informed him/her that the patient was in the waiting room. RN #3 noted that shortly afterward an officer came into the main ED reporting that a knife was taken away from a person (Patient #4) in the waiting room. RN #3 noted that Patient #4 did not express wanting to be checked back into the ED, did not ask to be registered again, did not ask to be re-evaluated, and was not refused care by RN #3, RN #5, or physician #2. RN #3 noted that he/she witnessed physician #2 explain to the officer that the patient had just been medically evaluated and discharged home. In addition, RN #3 noted that he/she also witnessed physician #2 explain to the officer that Patient #4 could check back into the ED to be evaluated for any psychiatric complaints but if the patient chose not to check back into the ED the patient could not loiter and could be escorted off hospital property.

At 6:18 p.m., physician #2 noted that after Patient #4 was discharged the patient went into the waiting room and called County 'A's Sheriff Office. Physician #2 noted that he/she was informed by an officer that Patient #4 had called reporting he/she was suicidal. Physician #2 noted that he/she informed the officer that the patient had been evaluated, had denied suicidal ideations, and had then been discharged from the ED. Physician #2 further noted that he/she informed the officer that Patient #4 should not remain in the waiting room unless the patient wanted to check back in to be seen. Physician #2 noted that he/she had no further interactions with the patient after the patient ' s initial discharge.


Review of the receiving hospital's medical record for Patient #4 revealed the patient was brought in by County 'A's Sheriff Officers on 03/15/17 at 5:27 p.m. The patient was triaged as a level 2 Emergent patient at 5:55 p.m. The triage nurse noted that the patient was alert to person, had appropriate judgment, was somewhat uncooperative, and was having thoughts of harming himself/herself or others. At 6:00 p.m. the ED physician noted that the patient's physical exam was normal and that the patient denied suicidal or homicidal thoughts. A Behavioral Health Consult was ordered and the consultation was performed at 10:30 p.m. The Behavioral Health exam revealed the patient was suicidal with a plan. At 11:00 p.m., the ED physician ordered the patient to be placed on a 1013 (Georgia law that allows a patient to be held involuntarily when the patient has been determined to be a threat to self or others). The transfer form revealed the patient was transferred to a psychiatric inpatient facility.


Sheriff Officer's Note

Review of the County 'A's Sheriff Officer's notes dated 03/15/17 at 5:01 p.m. revealed two (2) officers responded to Trinity Hospital in reference to a suicidal person. The section of the report titled "Status/Description" listed patient #4 as "Mentally incompetent Person." The officer noted that Patient #4 was found in the lobby of Trinity Hospital and that the patient reported that he/she was feeling "really" suicidal and wanted to also do harm to others. The officer noted that Patient #4 reported being evaluated for chest pain and then released. The officer further noted that he/she "spoke with hospital staff in an effort to get (Patient #4) evaluated for his/her suicidal thoughts". The officer noted that staff reported that Patient #4 had signed the discharge papers " F*** You " and that the patient needed to be escorted off of the property. The officer noted that Patient #4 was transported to the receiving hospital to be evaluated. The Sheriff Officer also documented that a body cam was worn. Trinity Hospital of Augusta failed to re-evaluate patient #4 on 03/15/2017 for his psychiatric complaint of suicidal ideations, when a request was made by County 'A' Sheriff Officer for a re-evaluation for his psychiatric complaints; despite the patient having a knife on his person in the ED waiting area and complained of feeling suicidal, and wanting to hurt others.


On 03/27/17 at 1:50 p.m., the video recording from 03/15/17 was reviewed and revealed the following:
--At 6:36 p.m., (the Security Officer explained that the facility's clock on the video was actually "about 90 minutes fast and that the actual time of the occurrence was approximately 5:06 p.m. " two (2) County 'A's Sheriff Officer are observed entering the main ED waiting room and going through to the secondary waiting room.
--At 6:37 p.m., a third officer is observed entering the main ED waiting room and going through to the secondary waiting room. The Security Officer explained that the second waiting room did not have video cameras.
--At 6:42 p.m., the three (3) officers are observed leaving the ED with Patient #4. Patient #4 had on long pants, a blue short sleeved shirt, and shoes. The patient left the ED in a calm manner and did not have any form of restraints in place.


Professional Services Agreement

Review of the ED Professional Services Agreement revealed the contracted service began on 07/01/15 and was a three (3) year period. This contract required the ED providers to abide by state and federal laws.

Quorum Health Corporation of Code of Conduct

Review of the facility's Quorum Health Corporation Code of Conduct revealed all credentialed staff were required to sign a form acknowledging that they agreed to abide by the compliance of policies, federal, state, and local laws, and rules and regulations of the facility.


Interviews

During a telephone call on 03/27/17 at 3:00 p.m., the County 'A's Sheriff Office Dispatcher reported that the three (3) officers who responded to Trinity hospital on [DATE] were off duty and would not return until 03/29/17. A request was made to have the officers return the call. As of 03/31/17 none of the officers had returned the call.

During an interview on 03/27/17 at 2:30 p.m. in the Conference Room, the Registrar #4 confirmed that he/she remembered Patient #4. The Registrar explained that after Patient #4 was discharged three (3) County 'A's Sheriff Officers came to the ED, spoke with Patient #4, and then spoke with physician #2. The Registrar stated that he/she spoke with Patient #4 just prior to the patient leaving and tried to get the patient to sign back into the ED. The Registrar stated he/she was informed by an officer that physician #2 wanted the patient removed from the premises. The Registrar added that he/she did not hear the conversation between the doctor and the officer and did not know why the officer knows why. The Registrar said that law enforcement usually only removed individuals that were loitering, threatening, violent, or abusive. The Registrar stated Patient #4 had not appeared violent to him/her. The Registrar stated he/she had worked at the facility for ten (10) years and was familiar with EMTALA requirements.

During a telephone interview on 03/27/17 at 3:00 p.m. in the Conference Room, ED Physician #2 explained that after discharging Patient #4 he/she did not see the patient again. The physician explained that Patient #4's chief complaint had changed from stroke to chest pain, to arm pain, to not knowing why he/she was in the ED. Physician #2 stated the Patient #4's physical examination was normal and that the patient had denied any suicidal or homicidal thoughts. Physician #2 explained that he/she did not order a mental health evaluation because there was nothing to indicate that the patient needed to have a mental health evaluation. Physician #2 stated that he/she felt Patient #4 was competent. Physician #2 said that after Patient #4 was discharged he/she was notified that Patient #4 went into the waiting room and called County 'A's Sheriff Office. Physician #2 confirmed that he/she spoke with an officer and informed the officer that he/she had just evaluated and discharged Patient #4. Physician #2 stated that he/she informed the officer that Patient #4 had denied suicidal or homicidal thoughts. Physician #2 said the officer informed him/her that the patient was reportedly suicidal and that he/she told the officer that Patient #4 could be signed back into the ED and he/she would be happy to evaluate and provide any medical treatment needed. Physician #2 stated that he/she never refused to see Patient #4. Physician #2 further explained that all patients who come on hospital property requesting treatment receive an MSE. Physician #2 confirmed that he/she had received EMTALA training. The hospital failed to ensure that their own policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination for patient #4 on 3/15/2017. As the County Sheriff Officer was acting on behalf of the patient, as an observer who believed based on the patients behavior, he/she requested Physician #2 to examine and/or treat Patient #4's new complaint of suicidal ideations on 3/15/2017.

During a telephone call interview on 03/28/17 at 9:00 a.m., Ambulance Service 'A's Dispatcher reported that the two (2) ambulance attendants that transported Patient #4 to Trinity hospital on [DATE] were off duty. A request was made to have the officers return the call. As of 03/31/17 none of the officers had returned the call.

During an interview on 03/28/17 at 10:30 a.m. in the Conference Room, RN #5 confirmed that he/she had been Patient #4's primary nurse and that he/she remembered Patient #4. RN #5 explained that Patient #4 was confused and didn't recall why he/she had called the ambulance. RN #5 stated Patient #4 had been dressed appropriately in long pants, a shirt, and shoes. RN #5 stated that Patient #4 was oriented and had listed a brother but did not give the brother's phone number. The nurse said Patient #4 stated that he/she lived in the woods. RN #5 explained that Physician #2 examined Patient #4 and gave orders for Patient #4 to be discharged . The nurse went on to explain that Patient #4 expressed disbelief that he/she (the patient) was being discharged . RN #5 stated the patient was angry that he/she had been discharged and signed the discharge forms " F*** It ". RN#5 said the patient wanted to use the phone and was informed that the ED did not have portable phones and that once discharged the patient could use the phone in the waiting room. RN #5 said that he/she did not have any contact with the patient after the patient left the main ED. RN #5 explained that he/she was present when an officer entered the main ED to speak with physician #2. RN #5 stated the officer informed physician #2 that Patient #4 was in the waiting room threatening to kill himself/herself. RN #5 said physician #2 informed the officer that Patient #4 was evaluated and had not been suicidal or homicidal at the time of the examination, but if the patient wants to be seen again the patient needs to sign back into the ED. RN #5 stated the officer never asked for the patient to be signed back into the ED. RN #5 said the officer asked physician #2 if the doctor was refusing to see Patient #4 to which physician #2 responded no I ' m not refusing to see the patient but the patient needs to be signed back into the ED. RN #5 said the physician repeated that he/she would be glad to see the patient once the patient was signed back into the ED.

During an interview on 03/28/17 at 10:55 a.m. in the Conference Room, RN #3 confirmed that on 03/15/17 he/she was the ED Charge Nurse. RN #3 stated he/she remembered Patient #4 because he/she had triaged the patient and performed the suicide risks assessment which had been negative for any current suicidal thoughts. RN #3 stated he/she did not see the patient again after the patient was triaged and placed in an ED room. RN #3 said that after Patient #4 was discharged an officer came into the main ED and informed the staff that a knife had been taken away from Patient #4 who was still in the waiting room. RN #3 said the officer asked me if we were going to see the patient again. RN #3 said the officer kept asking if we were refusing to see the patient and I told the officer twice that we were not refusing to see the patient. RN #3 explained that the officer then spoke with physician #2 and was informed by physician #2 that the patient had already been medically cleared. RN #3 said physician #2 informed the officer that if the patient was signed back into the ED the physician (#2) would see the patient again.